CLINICAL APPROACH TO HYPERTENSION
Drug Treatment of Hypertension
Based on JNC VII, WHO-ISH, BSH
Dr.Sarma RVSN, M.D., M.Sc
Consultant in Medicine and Chest,
JN Road, Jayanagar,
Tiruvallur, TN
Slide No 1
Globally Renowned Hypertension Societies
1. JNC VII – Joint National Committee on HT, USA
2. WHO-ISH – WHO - International Society on HT
3. EHS – European Hypertension Society
4. BHS – British Hypertension Society
5. CHS – Canadian Hypertension Society
6. NKF – National Kidney Foundation, USA
7. AKA – American Kidney Association, USA
8. AHA – American Heart Association, USA
9. ACC – American College of Cardiologist
Slide No 2
New Features and Key Messages
1. For persons over age 50, SBP is a more important than DBP as CVD
risk factor.
2. Starting at 115/75 mmHg, CVD risk doubles with each increment of
20/10 mmHg throughout the BP range.
3. Persons who are normotensive at age 55 have a 90% lifetime risk for
developing HTN.
4. Those with SBP 120–139 mmHg or DBP 80–89 mmHg should be
considered prehypertensive who require health-promoting lifestyle
modifications to prevent CVD.
5. Thiazide-type diuretics should be initial drug therapy for most, either
alone or combined with other drug classes.
6. Certain high-risk conditions are compelling indications for other drug
classes.
Slide No 3
New Features and Key Messages
7. Most patients will require two or more antihypertensive drugs to achieve
goal BP.
8. If BP is >20/10 mmHg above goal, initiate therapy with two agents, one
usually should be a thiazide-type diuretic.
9. The most effective therapy prescribed by the careful clinician will control
HTN only if patients are motivated.
10. Motivation improves when patients have positive experiences with,
and trust in, the clinician.
11. Empathy builds trust and is a potent motivator.
12. The responsible physician’s judgment remains paramount.
Slide No 4
JNC VII Classification
Category
SBP (mm Hg)
DBP (mm Hg)
Normal
< 120
< 80
Pre – hypertension
120-139
80-90
Stage 1
140 – 159
90 – 99
Stage 2
160 and above
100 and above
Hypertension
Slide No 5
BP Control Rates
Trends in awareness, treatment, and control of high
blood pressure in adults ages 18–74
National Health and Nutrition Examination Survey, Percent
1976–80
1988–91
1991–94
Awareness
51
73
68
70
Treatment
31
55
54
59
Control
10
29
27
34
1999–2000
Slide No 6
CVD Risk Factors
1. Hypertension*
2. Cigarette smoking
3. Obesity* (BMI >30 kg/m2)
4. Physical inactivity
5. Dyslipidemia*
6. Diabetes mellitus*
7. Micro-albuminuria or estimated GFR <60 ml/min
8. Age (older than 55 for men, 65 for women)
9. Family history of premature CVD
(in male relative under age 55 or female relative under age 65)
*Components of the metabolic syndrome.C
Slide No 7
Target Organ Damage (TOD)
•
Heart
Left ventricular hypertrophy (LVH)
Angina or prior myocardial infarction
Prior coronary revascularization
Heart failure (Systolic/diastolic dysfunction)
•
Brain
CVA Stroke or transient ischemic attack
•
Chronic kidney disease and RI
•
Peripheral arterial disease PVD
•
Hypertensive Retinopathy
Slide No 8
Target Organ Damage (TOD)
•
Routine Tests
•
Electrocardiogram, Echocardiography desirable
•
Urinalysis
•
Blood glucose (F and PP), and Hematocrit
•
Serum potassium, Creatinine or GFR, Calcium
•
Lipid profile complete
•
Optional tests
•
24 hr. urine albumin excretion or ACR
•
More extensive testing for identifiable causes is not
generally indicated unless is BP is uncontrolled
Slide No 9
Alpha and Beta Blockers
Site of Action
Cardiac muscle
Alpha 1 Blockers
Beta 1 Blockers
(Prazocin)
(Atenelol)
Increase rate
Decrease rate and
force
(effect is mild)
Cardiac conduction
system
No effect
Decrease the
conduction
Blood vessels
Vasodilators
Vasoconstrictors
Bronchial SM
Mild relaxation
Constrict
Trigone,
Stimulate
Inhibit
and sphincter
Slide No 10
Goals of Therapy
 Reduce CVD and renal morbidity and mortality.
 Treat to BP <140/90 mmHg or BP <130/80 mmHg in patients
with diabetes or chronic kidney disease.
 Achieve SBP goal especially in persons >50 years of age.
Slide No 11
Lifestyle Modification
Modification
Weight reduction
Approximate SBP reduction
(range)
5–20 mm/10 kg wt loss
Adopt DASH eating plan
8–14 mmHg
Dietary sodium reduction
2–8 mmHg
Physical activity
4–9 mmHg
Abstinence from alcohol
2–4 mmHg
Slide No 12
What to choose from the ocean
 16 different classes of drugs
 117 approved molecules as on date
 Innumerable drug combinations
 Over 1800 clinical trials of repute
 Five international guidelines
 Multiple target organs damage
 Many co-morbidities
 Varied outcomes of interest
 Cost constraints
 Other extraneous considerations
Slide No 13
Which drug should we prescribe ?
 Choice must be tailored to individual patient
 Should be rational and as per approved guidelines
 Only class1 evidence based medications to be used
 Suitable to patients’ purse
 Can never be arbitrary
Slide No 14
Anti-Hypertensive Drugs: Sites of Action
Blood Pressure
=
Cardiac Output
CO = HR X St volume
Beta Blockers
CCB - Verapamil
Diuretics - Indapamide
X
Total Peripheral Resistance
ACE Inhibitors
AT1 Blockers
Alpha 1 Blockers
Alpha 2 Agonists
CCB – Nefidepine Group
DA1 Agonists
Diuretics
Sympatholytics
Vasodilators
Slide No 15
Hypertension – Case specific approach
Case 1
Pre Hypertension (SBP < 140, or DBP < 90)
Case 2
Case 3
Case 4
Case 5
Case 6
Hypertension
Hypertension
Hypertension
Hypertension
Hypertension
stage 1 (SBP < 160, or DBP < 100)
stage 2 (SBP > 160, or DBP > 100)
with prior AMI or CHD
with IHD but No MI, Prinzemetal Angina
with high CHD risk
Case 7
Case 8
Case 9
Case 10
Hypertension
Hypertension
Hypertension
Hypertension
with LVH or LV dysfunction
with congestive heart failure or LVF
with tachycardia
with bradycardia, conduction blocks
Slide No 16
Hypertension – Case specific approach
Case 11 Hypertension with Diabetes mellitus sans nephropathy
Case 12 Hypertension with Diabetes mellitus with nephropathy
Case 13
Case 14
Case 15
Case 16
Hypertension with Renal failure sans DM
Hypertension with Dyslipidemia
Hypertension with Bronchial Asthma, COPD
Hypertension with Peripheral Arterial Disease (PVD)
Case 17
Case 18
Case 19
Case 20
Hypertension
Hypertension
Hypertension
Hypertension
with Benign Prostatic Hypertrophy
with Male Sexual Dysfunction (ED)
in Pregnant women and PIH
with Post Menopausal Osteoporosis (PMO)
Slide No 17
Hypertension – Case specific approach
Case 21 Hypertension with Gout
Case 22 Hypertension in the elderly (> 65 years)
Case 23
Case 24
Case 25
Case 26
Hypertension in the young (> 20 years)
Hypertension in a chronic smoker
Hypertension with associated cough
Secondary Hypertension – various causes
Case 27
Case 28
Case 29
Case 30
Case 31
Hypertension and Pheochromocytoma
Resistant Hypertension
Isolated Systolic Hypertension (ISH)
Hypertensive emergencies
Hypertension with Acute CVA (Stroke)
Slide No 18
Hypertension – Important Classes of Drugs
 Thiazide diuretics –
Hydrochlorothiazide - Aquazide, Hydrazide, Hydride
Chlorthalidone – Hythalton, Loop diuretic – Frusemide
 Potassium sparing
Triamterene, Amiloride, Spironalactone (Aldo anta)
 Beta blockers
Selective – Metoprolol, Metoprolol XL, Atenelol
Combined alpha and beta blockers – Carveidilol, Labetolol
 ACEI – Enalapril, Ramipril, Lisinopril, Quinapril, Perindopril
 ARB – Losartan, Valsratan, Candesartan, Irbesartan
 CCB – Nefedipine, Amlodipine, Varapamil, Diltiazem
 Alpha Blokers – Prazocin, Doxizocin, Tamsulocin
Slide No 19
Hypertension – Rational Drug Combinations
ACEI and ARB = A
Diuretics Drugs= D – Rank 1
Beta Blockers = B
ACEI and ARB = A – Rank 2
Calcium Channel (CCB) = C
Beta Blockers = B – Rank 3
Diuretics Drugs= D
CCB = C – Rank 4
D and A combination is excellent -
Ramace H, Losar H, Enace D
D and B combination next -
Betaloc H, Atecard D, Tenoric
D and C combination third -
Amlogaurd H, Stamlo D
A and B combination fourth -
Losar A, Cardif Beta
A and C combination fifth -
Amlopres L, Hipril A, Amlo LS
B and C combination sixth -
Amlo AT, Amlobet, Beta Nicardia
Slide No 20
Case 1
Pre Hypertension
(SBP < 140, or DBP < 90)
B.P Recording:
Two readings, 5 minutes apart,
sounds
disappearance
sitting in chair. Confirm ↑ reading
in contra-lateral arm. Systolicstarting, Diastolic -
Normal B.P :
SBP < 120, DBP < 80 mm Hg
Pre Hypertension :
SBP < 140, DBP < 90 in non diabetics
SBP < 130, DBP < 80 in Diabetics
No CHD risk, No TOD - present
Treatment :
Must start on Life style modification
No drug treatment needed now
Follow up :
Yearly, Health education on HT
Slide No 21
Case 2
Hypertension stage 1
(SBP < 160, or DBP < 100)
HT Stage 1
SBP < 160, DBP < 100 in non diabetics
No CHD risk, No TOD - present
Uncomplicated simple HT Stage 1
Treatment
Must start on Life style modification
Single drug to start with
Thiazide group drug first choice
ACEI -Enalapril Second choice
Beta blockers third choice
Not on goal – Combination D + A
Rationale
Diuretic, ACEI, Beta blocker –
all reduce mortality
Slide No 22
Case 3
Hypertension stage 2
(SBP > 160, or DBP > 100)
HT Stage 2
SBP > 160, DBP > 100
No CHD risk, No TOD - present
No other compelling indications
Uncomplicated simple HT stage 2
Treatment
Must start on Life style modification
Two drug combination, may need 3
Diuretic + ACEI – first choice
Diuretic + Beta blocker – second choice
Diuretic + CCB – third choice
Not on goal – Combination D + A + B
Rationale
Stage 2 will progress to TOD fast
Need to quickly achieve goal
Slide No 23
Case 4
Hypertension with prior AMI or CHD
HT + MI or CHD
SBP > 140, DBP > 90
Had MI or CHD+, TOD may be +
MI is the compelling indication
Treatment
Must start on Life style modification
Two drug combination, may need 3
Beat blocker + ACEI – first choice
Beta blocker + Spiranalactone. – 2nd choice
combined alpha + beta blockers
Carvediolol, Labetolol
ACEI + Spiranalactone – third choice
Not on goal – Combination B + A + Aldo
Rationale
ACC/AHA Post-MI Guideline, BHAT,
SAVE, Capricorn, EPHESUS
Slide No 24
Case 5
Hypertension with IHD, No MI, Prinz. Angina
HT + IHD
SBP > 140, DBP > 90
No MI but IHD+ in ECG or Treadmill,
TOD may be +, compelling indication +
Treatment
Must start on Life style modification
Two drug combination, may need 3
Diuretic + Carvediolol – 1st choice
Diuretic + ACEI – 2nd choice
if not on goal
D + B + C or D + B + A – combination
CCB if chosen – Diltiazem
Prinzmetal Angina
Vasospastic angina or ST ↑Angina
No Beta blockers, CCB first,
Alpha blocker second
Rationale
ALLHAT, HOPE, ANBP2, LIFE,
CONVINCE , PROGRESS
Slide No 25
Case 6
Hypertension with high CHD risk
HT, High CHD risk
SBP > 140, DBP > 90
No MI or IHD in ECG or Treadmill,
More than 2 risk factors for IHD +
Treatment
Must start on Life style modification
Must correct the risk factors quickly
Single drug, may need combination of 2
ACEI – first choice, if not on goal
Perindopril + Beta blocker – 2nd choice
Diuretic + Beta blocker – third choice
Not on goal – Combination D+A+B
Rationale
ALLHAT, HOPE, ANBP2, LIFE,
CONVINCE
Slide No 26
Case 7
Hypertension with LVH or LV Dys fun.
HT LVH or LVD
SBP > 140, DBP > 90
NO IHD or MI.
TOD – LVH or LV dysfunction +
Treatment
Must start on Life style modification
Single or Two drug combination
ARB – 1st choice - Losartan
ACEI - 2nd choice - Ramipril
Beta blocker – 3rd choice - Metoprolol
Not on goal – Combination A + B
Rationale
LVH is an independent predictor
of mortality. Must quickly corrected
Diastolic Dys. ACEI – Ramipril –HOPE
Systolic Dysfunction – A + B or A+D
Do not give
Hydralazine or Minoxidil contraindicated
Alpha blockers or CCB with caution
Slide No 27
Case 8
HT + CHF or LVF
Hypertension with CHF or LVF
SBP > 140, DBP > 90
NO IHD or MI. TOD LVH, LV dys +
Has CHF or LVF - TOD
Treatment
Must start on Life style modification
Two drug combination for CHF
Diuretic + ARB– first choice - Losartan
Diuretic + ACEI – second choice Rami or Ena
Diuretic + ACEI + Beta blocker (if not
decompensated)
ACEI + BB for LVF, Furesemide in CHF
Not on goal – Combination D + A + B
Rationale
CHF / LVF are independent predictors
of mortality. Must quickly be corrected
ACC/AHA HF Guideline, MERIT-HF,
COPERNICUS, SOLVD, TRACE
Do not Give
Alpha blockers, CCB
Slide No 28
Case 9
Hypertension with tachycardia
HT + Tachycardia
SBP > 140, DBP > 90
Sinus Tachycardia HR > 100 or PAT
Treatment
Single drug to start with
Beta blocker – first choice – Metoprolol,
If not on goal Beta blocker + ACEI
PAT – CCB – Verapamil
Add adenosine or cardarone if needed
Rationale
Uncontrolled tachy precipitates LVF, CHF
Evaluate tachy – ↑Thyroid, Anemia, CHF
Do not give
CCB - nefidepine group, Alpha blockers
No Propranolol – Non selective
No Reserpine – reflux tachycardia
Slide No 29
Case 10
Hypertension with bradycardia
HT + bradycardia
SBP > 140, DBP > 90
Sinus bradycardia HR < 60, May be HB
Treatment
Single drug to start with
CCB – first choice - Amlodepine, Nefidepine
If not on goal CCB + ACEI
May be on Beta blocker – stop it
Alpha blockers may be considered
Rationale
Brady precipitates ↓CO - LVF, CHF
Evaluate brady- may be HB, ↓Thyroid
Do not give
Beta blockers, CCB - Verapamil
Slide No 30
Case 11
Hypertension with Diabetes – no nephropathy
HT + DM, No Nephro-
Stage 1 or 2 cut off values 10 mm lower
No nephropathy, proteinuria may be +
Treatment
Must start on Life style modification
Hb A1c to be kept below 6.5
ARB 1st choice
ACEI second choice
CCB or BB are good add on drugs
Rationale
Diuretics not a good choice –
Effect on DM, Lipids, fluid excretion.
NKF-ADA Guideline, UKPDS, ALLHAT
Alpha blockers may useful in DM peripheral neuropathy
Slide No 31
Case 12
Hypertension + Diabetes + nephropathy
HT + DM, Neph +
Stage 1 or 2 cut off values 10 mm lower
Nephropathy ++, proteinuria ++
Treatment
Must start on Life style modification
Hb A1c to be kept below 6.5
ARB / ACEI 1st choice if Creat. < 3 mg
Sr Creatinine > 3 mg ACEI / ARBs stop
Methyldopa, Hydralazine if Cr is > 3 mg
Diuretics are good choice + BB add on
Rationale
NKF-ADA Guideline, UKPDS, ALLHAT
Potassium sparing diuretics caution
Quick control of HT – DM is high risk
Do not give
CCB – because of fluid retention
Slide No 32
Case 13
Hypertension with Renal failure
HT + MRD+
Usually stage 2 HT SBP >160, DBP >100
Nephropathy ++, proteinuria ++
Treatment
Must start on Life style modification
ACEI/ ARB 1st choice if Creat. < 3 mg
Sr Creatinine > 3 mg ACEI / ARBs stop
Methyldopa, Hydralazine if Cr is > 3 mg
Diuretics are good choice + BB add on
Rationale
NKF Guideline, Captopril Trial, RENAAL,
IDNT, REIN, AASK
Do not give
CCB – fluid retention
Avoid ACEI / ARB if hyper kalemia +
Slide No 33
Case 14
Hypertension with Dyslipidemia
HT + Dyslipidemia
Stage1 or 2 HT
If Dyslipidemia ↑LDL,↑TG, ↓HDL
Treatment
Must start on Life style modification
ACEI/ ARB 1st choice
CCB 2nd choice
Alpha blockers are lipid favourable
Rationale
Use Lipid favourable drugs
Statins / fibrates no interaction with HT drugs
Do not give
Diuretics, Beta blocker – Lipid unfavourable
Slide No 34
Case 15
Hypertension with Bronchial Asthma, COPD
HT + Astma, COPD
Stage1 or 2 HT
Known BA, COPD
Treatment
Must start on Life style modification
ACEI/ ARB 1st choice
Diuretics first choice if Corpulmonale +
CCB 2nd choice,
Rationale
Smoking must be discontinued
No Beta adrenergic receptor blockade
Do not give
No Beta blokers, Alpha blockers neutral
Oral steroids to be strictly avoided
Inhaled salbutamol / steroids no contra indication
Slide No 35
Case 16
Hypertension + Peripheral Vascular Disease
HT + PVD, TAO
Stage1 or 2 HT
PVD, TAO, Raynauds
Treatment
Must start on Life style modification
CCB first choice
Alpha blockers 2nd choice
May use ACEI, Hydralazine
Evaluate for CHD thoroughly
Aspirin must be used
PVD is equal to Coronary Disease
Rationale
Smoking must be discontinued
No Beta Adrenergic receptor blockade
Do not give
No Beta blockers
Slide No 36
Case 17
Hypertension with Benign Prostatic Hypertrophy
HT + BPH
Stage1 or 2 HT
Prostatism, BPH
Treatment
Must start on Life style modification
Alpha blockers (Prazocin) + ACEI/ ARB
Diuretics not good choice
Tamsulosin (BPH) + ACEI or CCB for HT
Rationale
Use trigone stimulants, avoid suppress.
Postural hypotension with Prazocin
Do not give
Beta blockers not indicated
Slide No 37
Case 18
Hypertension with Male Sexual Dysfunction (ED)
HT + MSD (ED)
Stage1 or 2 HT
MSD +
Treatment
Must start on Life style modification
Alpha blockers 1st choice
May use ACEI, Hydralazine, CCB
Diabetes mellitus is common cause
Evaluate for MSD, may be psychological
HT without IHD is no contra for Sildenofil
Rationale
Smoking to be discontinued
No Beta Adrenergic receptor blockade
Sildenofil contra with Nitrates
Do not give
No Beta blockers, No diuretics
Slide No 38
Case 19
Hypertension in Pregnant women and PIH
HT in Pregnancy
Stage 1 or 2 HT
May be PIH or Pregnancy in a HT lady
Treatment
Alpha Methyl dopa 1st choice
CCB 2nd choice
Hydralazine may be used
B – only Labetolol IV
Tight HT control is essential
Rationale
If smoker, must be discontinued
Do not give
ACEI / ARB are contraindicated
Avoid Beta blockers until 28 wks
Diuretics use with caution – only if wet
Slide No 39
Case 20
Hypertension in Women ( PMW, PMO)
HT in Women
Stage 1 or 2 HT
Pre menopausal, PMW or PMO
Treatment
Same as any other Ht
HRT No risk for ↑BP–
ERT risk benefit to be weighed
DVT, IHD must be excluded
Diuretics good in PMO
Rationale
HRT – ERT to be carefully decided
In childbearing age HT – don’t use OCP
Diuretics no risk in PMO
They help bone re-mineralization
Slide No 40
Case 21
Hypertension in Gout
HT + Gout
Stage 1 or 2 HT
Gout or hyperuricemia – UA > 8 mg
Treatment
Same as any HT except No Diuretics
Uricoseuric drugs (Allopurinal) no contra
Rationale
Thiazides increase serum uric acd
Oral steroids increase serum uric acid
Do not give
No Diuretics particularly Thiazides
Oral steroids to be avoided
Slide No 41
Case 22
Hypertension in the elderly (> 65 years)
HT in > 65+
Stage 1 or 2 HT
Age 65+, co-morbidities may be +
Treatment
Same as any HT except lower initial doses
Postural HT is a major hazard
Diuretic or D+ACEI, SBP must be below 150
Rationale
Lowest rates of HT control in this group
More than 2/3 in 65+ yrs are HT
HT – CVA risk is high in this group
Beta blocker – use with care.
Special care
Avoid volume depletion, rapid titration of
drugs, Check BP in upright position
Do not give
Guanethadine, Clonidine
Prazocin with care for fear of PH
Slide No 42
Case 23
Hypertension in the young (> 20 years)
HT in < 20
Stage 1 or 2 HT
Age 20, May be secondary HT
Treatment
Good try of life style interventions first
Same as any HT - smaller doses suffice
Search for Secondary causes
Diuretic or D+ACEI
Rationale
Uncomplicated Ht no contra for physical
Activity. Secondary causes must be treated
Slide No 43
Case 24
Hypertension in a chronic smoker
HT in smokers
Stage 1 or 2 HT
Chronic smoker > 10 cig/day, > 5 years
Treatment
Stop smoking once HT is detected
Life style interventions must
Same as any HT except for use of B
Alpha blockers may be used
Rationale
Smokers with HT have manifold risks of
Atheroscleorotic vascular disease
May have COPD, PVD - so
Do not give
Beta blockers
Slide No 44
Case 25
Hypertension and cough
Hypertensives may present with cough – watch out
1. Consider LVF
2. Consider ACEI induced dry cough
3. Stop ACEI and give ARB or other agents
4. Check the composition of the cough remedy you give
5. Ephedrine, Pseudephedrine, should be avoided
6. Oral Beta agonists like Orciprenaline, Salbutamol, Terbutaline
the less used, the better.
7. Inhaled beta agonists are safe
8. Decongestants like phenylpropanolamine to be avoided
Slide No 45
Case 26
Secondary Hypertension – various causes
Secondary HT
Usually Stage 2 HT
Secondary causes will be present
May present in young individuals
Treatment
Look for secondary cause and treat
Life style interventions must
Vigorous efforts required to control HT
Often two or even 3 drugs may be required
Resistant HT may be encountered
Rationale
Anti HT drugs as per secondary cause
Absolute contra
ACEI or ARB in bilateral renal artery stenosis
Slide No 46
Case 27
Secondary HT in Pheochromocytoma
Pheochromocytoma
Usually Stage 2 HT, Episodic or Labile
Secondary adrenal medullay tumor
May present in young individuals
Treatment
Surgical Ablation of the chromaffin tissue
HT needs to be controlled before surgery
Alpha blockers are the drugs of choice
Phentolamine, Phenoxybenzamine, Prazocin
Vigorous efforts required to control HT
Often two or even 3 drugs may be required
Resistant HT may be encountered
Rationale
First reduce HT, then surgery
Do not use
Beta blockers
Slide No 47
Case 28
Resistant Hypertension
Resistant HT
Usually Stage 2 HT
May present in young individuals
May have secondary causes
Reasons
Not taking medication (liars)
Improper BP measurement
Excessive Na intake, Inadequate diuretic Rx.
Full doses of drugs not employed
Drug interactions – NSAIDs, SMA, OCP, OTC
Herbal remedies, Excessive alcohol use
Rationale
Identify the above and correct
Secondary causes to be searched for
Slide No 48
Case 29
Isolated Systolic Hypertension (ISH)
ISH
SBP > 140 persistently but DBP < 90
Occurs in elderly, Usually SBP is >160
Diuretics 1st choice – Indapamide SR
Treatment
CCB – Amlodepine is an alternative 1st
ACEI / ARB second choice
Rationale
SHEP, SystEur, STOP-H, MRC II
Do not use
Beta blockers – no evidence on mortality data
HT and Migraine – Beta blockers are the choice
Slide No 49
Case 30
Hypertensive emergencies
HT emergency
Marked DBP elevation
Acute TOD present
TOD Presentation
Encephalopathy, MI, ACS, Pul Edema,
eclampsia, stroke, head trauma, lifethreatening arterial bleeding, or aortic
dissection
Treatment
With TOD immediate admission to ICU
IV Nitroprusside, Diazoxide, Labetolol
Without TOD Combination of 2 or 3 drugs
Close monitoring
Life style modification not now – no time
Do not use
No sublingual nefedipine,
Slide No 50
Case 31
Hypertensive with Acute CVA (Stoke)
HT + CVA (Stroke
Marked DBP elevation
May be SAH, ICH, Acute CI
Rationale
In acute setting, no consensus on
treatment of elevated BP
HT at time of an acute stroke associated
with increased risk of cerebral hemorrhage
and edema, increased mortality
After acute ischemic stroke, cerebral
auto regulation affected
Active treatment of BP in the first 7 days
could worsen symptoms
Treatment
Recommendation not to start HT Rx.
before 7 to 10 days after ischemic stroke
Slide No 51
Current Indications for Alpha Blockers
1. Hypertension with BPH
2. In Pheochromoytoma before surgery
3. In the treatment of Ergot over dose
4. Raynaud’s syndrome and PVD, TAO
5. Vasospastic (prinzemetal Angina)
6. Diabetic neuropathy
7. Hypertensive smokers
8. Hypertension with dyslipidemia
First dose syncope and Postural Hypotension
can be avoided by starting low dose and giving at bed time
Slide No 52